Components of Timely Antibiotic Administration in Sepsis

SUMMARY

  • There are at least 2 components to consider in timely antibiotic use in sepsis patients.
  • The time from triage to ordering antibiotics caused four-fifths of the delay in meeting the 3-hour bundle goal.
  • Both recognition and administration delays were associated with hospital mortality risk.
  • The hour-1 bundle recommendation for antibiotic initiation may be too aggressive and lead to excessive use.

BACKGROUND

  • Up to 40% of patients initially treated for sepsis are later found to have a low likelihood of infection.
  • Aggressive time to antibiotic administration in sepsis patients has generated significant controversy between the rapid initiation to minimize adverse outcomes and the risks of promoting antibiotic resistance and toxicity.
  • Current guidelines recommend antibiotic initiation within 1 hour (Surviving Sepsis Campaign) or within 3 hours (CMS SEP-1 quality measure) of sepsis recognition.
  • Previously, analysis of antibiotic timing relative to mortality have blended together 2 components of administration. These are:
    a. Time from recognition of sepsis to antibiotic ordering
    (Recognition Delay
    b. Time from antibiotic ordering to infusion (Administration delay)
  • It remains unclear which time interval actually impacts mortality.

REVIEW

  • A recent retrospective analysis from Atrium Health (12 hospital system in the Southeast) evaluated antibiotic orders for mortality, in:
    • 28,865 ED patient encounters
    • 24,093 patients with suspected sepsis
    • 3,681 patients with septic shock
  • Mortality was correlated with (P<0.01):
    • Recognition time (hours from ED triage to antibiotic order)
    • Administration time (hours from antibiotic order to antibiotic infusion)
      • There was a greater odds ratio of mortality in patients with order to infusion delay between 1.5 to 2.5 hours compared to 30 minutes.

CONCLUSIONS

  • Allowing longer times for additional diagnostic considerations prior to initiation of antibiotics may be reasonable for patients with suspected sepsis.
  • The bundle element of timely antibiotic administration has typically been considered as one blended item, rather there are 2 areas which should be considered in any sepsis program.
  • Both recognition and administration delays were associated with hospital mortality risk.
  • Triage time to order time had the greatest contribution to delays in antibiotic administration.

Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (erkan@spo.icu), or video chat.